Is infant male circumcision an abuse of the rights of the child? Yes

doi:10.1136/bmj.39406.520498.AD

BMJ 2007;335:1180 (8 December), doi:10.1136/bmj.39406.520498.AD

Head to head

Is infant male circumcision an abuse of the rights of the child? Yes

Geoff Hinchley, accident and emergency consultant

¹ Barnet and Chase Farm NHS Trust, Enfield, Middlesex EN2 8JL

geoff.hinchley{at}bcf.nhs.uk

doi: 10.1136/bmj.39406.523762.AD

Most circumcisions take place for religious rather than medicalreasons. Geoff Hinchley argues that the practice is harmfuland should be stopped but Kirsten Patrick believes that thefuture sexual health benefits justify parental choice

Improved understanding of the normal anatomy of the infant foreskinmeans there is now rarely a therapeutic indication for infantcircumcision,¹ and the procedure is not supported by internationalmedical opinion.² Ritual (non-therapeutic) male circumcision,however, continues unchecked throughout the world, long afterfemale circumcision, facial scarification, and other ritualforms of infant abuse have been made illegal. The law and principlespertaining to child protection should apply equally to bothsexes, so why do society and the medical profession colludewith this unnecessary mutilating practice?

Ritual male circumcision is an ancient religious rite for Muslimsand Jews, and the crux of this debate revolves around the primacyof parental religious conviction versus the primacy of the humanrights of the child, the preservation of its bodily integrity,and its right of self determination.

In addition to religious justification, there have been manyspurious and now unsupported health claims for circumcision—includingthe prevention of penile cancer, masturbation, blindness, andinsanity³—most of which, like reduction in HIV transmissionidentified more recently, relate to adult sexual behaviour andnot to the genital anatomy or best interest of a child. Theremay be a case that male circumcision reduces HIV risk in sexuallyactive adults, but the decision about whether to have this procedureshould be left until the person is old enough to make his owninformed healthcare choices.

Male genital mutilation is not a risk-free procedure. Thereare potential anaesthetic risks, and the short term risk ofbleeding and infection associated with any surgical procedure.⁴Longer term potential complications include pain on erection,penile disfigurement, and psychological problems.⁵ A recentreport shows that the non-circumcised adult penis is more sensitivethan the circumcised penis, largely because the five most sensitiveareas, identified in the study, are removed during circumcision.⁶This implies a reduction in future sexual sensitivity for circumcisedadults. Far from being a harmless traditional practice, circumcisiondamages young boys.

Legal protection

Article 24(3) of the UN convention on the rights of the childcommits all ratifying states to "take all effective and appropriatemeasures with a view to abolishing traditional practices prejudicialto the health of children" and article 19(1) says: "States shalltake all appropriate legislative administrative social and educationalmeasures to protect the child from all forms of physical ormental violence, injury or abuse."⁷

UK courts have interceded in the past to protect the best interestsof children whose parental belief systems have put childrenat risk. However, male circumcision remains lawful if both parentsconsent.⁸⁹¹⁰ Since the Human Rights Act has been implemented,however, single parental consent has been found to be insufficientto show that the procedure is in the child’s best interest.¹¹

As far as female genital mutilation is concerned, in the UnitedStates the Federal Prohibition of Female Genital MutilationAct states that in applying the law, "no account shall be taken. . . that the operation is required as a matter of custom orritual." These terms are closely mirrored in the UK Female GenitalMutilation Act 2003. Both the US and the UK legal systems thereforediscriminate between the sexes when it comes to protecting boysand girls from damaging ritual genital mutilation.

The UK’s General Medical Council abdicates all responsibilityfor male circumcision to society as a whole,¹² but in June 2007the BMA, which had previously offered general guidance,¹³ decidedthat "any decision to provide medical or surgical treatmentto a child, or any decision to withhold medical or surgicaltreatment from a child, should: consider the ethical, culturaland religious views of the child’s parents and/or carers,but without allowing these views to override the rights of thechild to have his/her best interests protected."¹⁴

Male circumcision was not specifically mentioned, but it cannotbe in the best interest of a child to be subjected, withoutits consent, to an irreversible surgical procedure, often withoutanaesthetic, which will provide no medical benefit but whichhas proved adverse consequences both in terms of potential complicationsfor some and reduced penile sensation in adulthood for all.

Religious perspective

Some faiths view male circumcision, often done by people whoare not medically qualified, as important for entering a covenantwith their God. However, given the age of the children involvedit cannot be said that this covenant is freely entered intoby the individual concerned.

In the US, elements of the Jewish community are beginning torethink this issue.¹⁵ They suggest bringing Jewish boys intothe covenant symbolically, with the potential for the childto be circumcised when old enough to consent to the procedurehimself. Muslims already circumcise boys at an older age, andfurther delay to allow the child to consent could equally beconsidered. How much stronger would that covenant be, when enteredinto by a fully competent young man with full knowledge of itsreligious implications and the potential risks involved.

The unpalatable truth is that logic and the rights of the childplay little part in determining the acceptability of male genitalmutilation in our society. The profession needs to recognisethis and champion the argument on behalf of boys that was sosuccessful for girls.

doi: 10.1136/bmj.39406.523762.AD

Competing interests: None declared.

References

British Association of Paediatric Surgeons, Royal College of Nursing, Royal College of Paediatrics and Child Health, Royal College of Surgeons of England and Royal College of Anaesthetists. Statement on male circumcision. London: RCS, 2001.
Hofvander Y. Circumcision in boys: time for doctors to reconsider. World Hosp Health Services 2002;8(2):15-7.
Smith J. Male circumcision and the rights of the child. Netherlands Institute of Human Rights, 1998. www.nocirc.org/legal/smith.php.
Williams N, Kaplia L. Complications of circumcision. Br J Surg 1993;80:1231-6.[Web of Science][Medline]
Peterson SE. Assaulted and mutilated. A personal account of circumcision trauma. In: Denniston GC, Hodges FM, Milos MF, eds. Understanding circumcision.New York: Kluwer Academic, 2001;271.
Sorrells ML, Snyder JL, Reiss MD, Eden C, Milos MF, Wilcox N, et al. Fine touch pressure thresholds in the adult penis. BJU Int 2007;99:864-9.[CrossRef][Web of Science][Medline]
United Nations. Convention on the rights of the child. www.ohchr.org/english/law/pdf/crc.pdf.
Re J (A Minor) (prohibited steps order: circumcision). [2000] 1 FLR 571.
Re J (child’s religious upbringing and circumcision). [2000] 1 FCR 307.
Re J (specific issue orders: Muslim upbringing and circumcision). [2000] 52 BMLR 82.
Re S. (Children) (Specific issue: circumcision) [2005] 1 FLR 236.
General Medical Council. Guidance for doctors who are asked to circumcise male children. London: GMC, 1997.
BMA. The law and ethics of male circumcision—guidance for doctors. London: BMA, 2006.
BMA. Annual representative meeting policies, June 2007. Ethics and professional responsibilities. www.bma.org.uk/bmapolicies.nsf/WF?OpenForm&key=Annual+Representative+Meeting.
Moss L. The Jewish roots of anti-circumcision arguments. Second international symposium on circumcision, San Francisco, California, 30 April-3 May 1991. www.nocirc.org/symposia/second/moss.html.

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